The impact of COVID‐19 pandemic lockdown on smoking habits and lifestyle: A cross‐sectional study

Abstract Background and Aims Throughout the COVID‐19 lockdown, the resultant psychological disturbances led to more tobacco consumption and deteriorated smoking behaviors among smokers. In this study, we aimed to investigate the impact of the COVID‐19 pandemic on the smoking behaviors of the Jordanian population. Methods A cross‐sectional online survey was designed using the Google Forms service and distributed by social media platforms. Responses were collected starting from November 12, 2020, until November 24, 2020. Results A total of 2511 respondents completed the survey, 77.3% were females. Males were significantly smoking more than females (p < 0.0001). Smoking was significantly more common among respondents who were older than 18 years old, married, held master's and PhD degrees, and working in non‐health‐related fields (p < 0.0001). Participants who smoke were more likely to adopt an unhealthy lifestyle during the pandemic. Females who started smoking last year were 2.6‐fold more than males (p < 0.0001). We also noticed that there is a significant relationship between those who started smoking and are <18 years, living in a family consisting of seven members or more, being unemployed, having a diploma or bachelor's degree in a health‐related major, having no chronic illnesses, increasing of daily meals or night meals, almost daily sugar intake, starting to follow social media account concerning physical activity, exercising once or twice a week, and sleeping more hours per day since the beginning of the pandemic (p < 0.01). Conclusion The results of our study showed that the lockdown had a significant impact on people's lifestyles including smoking habits. Most of our sample's smoker participants experienced a change in their smoking level mostly, an increase. While those who had a decrease in their smoking level experienced a somehow healthier lifestyle regarding nutrition and other aspects.


| INTRODUCTION
The World Health Organization (WHO) declared the novel coronavirus infection  pandemic (SARS-CoV-2) a global health crisis in January 2020. 1,2 To decelerate virus transmission, many governments globally restricted the activities of their population with the implementation of strict "lockdown" measures. 3 Between March and May 2020, Jordan applied an emergency nationwide lockdown to limit the spread of infection. 4 The protective measures implemented also aimed to stop new cases that entered from surrounding countries by closing both land and air borders. 5 Although these limitations helped to contain the outbreak, they resulted in adverse effects that negatively impacted the everyday life of the population 6 due to social distancing and lack of contact. Consequently, this led to significant changes in lifestyle and daily habits. [7][8][9] The subsequent psychological issues as a result of the pandemic led to more tobacco consumption. 10 This tendency may be based on some smokers' belief that smoking contributes to an improvement in psychological symptoms: a lessening of depressive symptoms and an improvement in anxiety. 11 Moreover, an association has been established between physical isolation and lack of company during the pandemic and an increase in the average amount of cigarettes being smoked per day. 12 Tobacco smoking, which is considered an addiction, has various harmful effects on multiple body systems and contributes to pulmonary toxicity. 13 According to Global Youth Tobacco Survey data in 2014, the number of Jordanian students who have ever smoked any form of tobacco was overall 44%. 14 It is believed that the protective measures that limited the movement of the population as well as the financial impact of the pandemic may contribute to a reduction in tobacco consumption. 15 In light of the impact of smoking on respiratory health, smokers may have a greater concern compared to nonsmokers concerning contracting a respiratory infection such as COVID-19. 16,17 Given all the above, the COVID-19 pandemic is having a significant impact on people's smoking behavior during the lockdown.
Whether these impacts are positive or negative, the main purpose of this study is to summarize and discuss how smoking habits changed during the lockdown among a sample of the Jordanian population. The study targeted Jordanian people from all age groups and social/educational backgrounds. The total number of participants was 2511. At the beginning of the survey, we guaranteed that the data collected would only be used for this study and no other purpose. Cochran's formula has been used to calculate the sample size with precision level ± 0.5, confidence level = 95%, and estimated proportion = 0.5. The sample size in the study population exceeded the estimated sample size. 18

| Inclusion and exclusion criteria
All people who were ordinarily resident in Jordan since the start of the pandemic were eligible to complete the survey in the Arabic language. All participants that gave online consent for participation were included in this study.

| Data collection
The questionnaire was designed to involve multiple sections with a variety of questions. The questionnaire began by collecting sociodemographic data of the participant: age, gender, marital status (single or married), educational level (high school diploma or still in school, diploma or bachelor's degree in a health-related major, diploma or bachelor's degree in a non-health-related major and master's degree or PhD), occupation (health-related field, non-healthrelated field or unemployed), place of residence (city, village or refugee camps). Also, we asked the participants if they have a chronic disease and performed any physical activity or not.
The questionnaire included questions about certain lifestyle parameters before and after the pandemic lockdown including diet, number of meals, activity and exercise, app downloads, or started to follow any social media accounts concerning physical activity and exercise. The questionnaire further aimed to ascertain how many hours of sleep the participant managed as well as their smoking status. The study population was asked if they are smokers or not (including tobacco cigarettes, e-cigarettes, and water pipes), and how long they were smoking and if they had experienced any noticeable changes in smoking levels, whether an increase/decrease or no change and the factors that led to these changes. Likewise, we asked respondents, who noticed a change in their smoking habits whether an increase or a decrease in the frequency of smoking, to choose the suitable reasons for that change. The reasons were divided into health, social, and psychological factors, free time, and the general lockdown of cafés and public smoking lounges. The questionnaire was designed for this study according to the adopted parameters.
The questionnaire was validated and pretested by peers of medical and statistics at the Faculty of Medicine and the Department of Statistics.

| Statistical analyses
The data collected were analyzed using the Statistical Package for the

| Smoking status
In our sample, 245 males out of 570 were smokers (43.0%) in comparison with 233 females who were smokers out of 1941 (12.0%), meaning there is almost a fourfold likeliness that males smoke compared to females by (p value < 0.0001). Smoking was more common among respondents who were older than 18 years old and those who hold a higher educational degree (master's and PhD degrees). Of participants who work in non-health-related fields, 28.2% were smokers compared with 18.3% of those who work in health-related fields (p value < 0.0001). During the pandemic, participants who smoke were more likely to have decreased their number of daytime meals (19.2%) than nonsmokers (15.4%) (p value = 0.001). On the other hand, 50.2% of smokers declared that they had an increased number of nighttime meals in comparison with 37.6% of nonsmokers (p value < 0.0001). We also found that respondents who smoked were more likely to adopt an unhealthy lifestyle during the pandemic, demonstrated by the high frequency of fast-food intake (three to four times a week or almost daily; p value < 0.0001) and low frequency of fresh fruits and vegetable intake (once a week; p value = 0.003). Likewise, smokers were significantly associated with sleeping fewer hours since the beginning of the pandemic (p value = 0.001), living in a family consisting of three members or less (p value ≤ 0.0001), and having no change in their level of exercise (p value = 0.040; Table 2).
There was no significant difference with the place of residency, the presence of chronic disease, changes in weight, appetite or frequency of sugar, fat, and oil intake after the start of the pandemic, using electronic devices, exercise status, and frequency of exercise (p value for all > 0.05; Table 2).

| Starting to smoke
When the respondents were asked about the starting of smoking, However, 20 out of 275 single participants (7.3%) started smoking more than 10 years while 102 out of 203 married participants (50.2%) started smoking more than 10 years so married participants are more by 6.9-fold (p value ≤ 0.0001; Table 3).
We also noticed that respondents who started smoking during the last year were more likely to be those who had a diploma or bachelor's degree in a health-related major (35.8%) This is compared to those with a high school diploma or still in school (25.0%), diploma or bachelor's degree in non-health-related major (20.3%), and master's degree or PhD (5.1%; p value ≤ 0.0001).
While respondents who started smoking more than 10 years ago were more likely to be found those who had a master's degree or PhD (54.4%) than a high school diploma or still in school (34.4%), diploma, or bachelor's degree in non-health-related major (22.2%), and diploma or bachelor's degree in a health-related major (8.1%; p value ≤ 0.0001).
We also noticed that there is a significant relationship between those starting to smoke in the last year being under 18 years old  However, there was no significant difference between duration since starting smoking and place of residency, physical exercise performance, change in appetite, change in weight, fast food intake, fat and oil intake, fresh fruit and vegetable intake (p value for all >0.05; Table 3).

| Changing related to the smoking habits
Two hundred seventeen out of 478 smoker participants (45.4%) stated they had increased their tobacco consumption during the pandemic, 123 smoker participants (25.7%) tried to smoke less or quit smoking during the pandemic while 138 smoker participants (28.9%) noticed no change in their smoking level during the pandemic ( Figure 1).
Regarding smoking habits during the pandemic, 75.6% of participants who declared that they smoked less were mostly in the (18-35 years) age group. We noticed that most people who stated they were smoking less were more likely to download apps or follow social media accounts concerning physical activity and Exercise (47.2%). They also tended to have a decrease in their appetite (20.3%), to lose weight (24.4%), and to have no increase in the number of night meals (51.2%; p value for all were less than 0.05; Table 4).
On the other hand, those who stated they were smokers and were smoking more during the pandemic were: also mostly in the ( Note: Values are expressed as number and percentage from total respondents (n (%)). Variables are considered significant at p value < 0.05 and marked in bold.
T A B L E 3 Relationship between the duration from starting smoking and the other variables (n = 478).
When did you start smoking?

| Reasons for changing in smoking habits
The current study showed that 253 (74.4%) of the respondents declared that the main cause for the change in the smoking habit was free time and boredom due to the general lockdown and quarantine.

T A B L E 3 (Continued)
When did you start smoking?

| DISCUSSION
Smoking is a worldwide health problem with a socioeconomic burden. 19 Consistently, the current study, showed that the 18-35 age group individuals had a higher percentage of increased smoking in comparison with other age groups. However, there was no significant difference between gender and occupation and changes in smoking habits during the lockdown, which is consistent with the results conducted in Belgium. 25 The current findings showed an increase in smoking habits among males during the COVID-19 lockdown (43%) compared to the females' group (12%). This is consistent with an Italian study that showed an increase in male smokers (49.3%) during the COVID-19 lockdown compared to a 22.2% increase in female smokers. 10 In addition, the current study showed an increase in the smoking habit in 45.4% of the study population during the lockdown which is similar to the Italian study (36%). In this study, the individuals who declared changes in their smoking habits attributed these changes to monotony, increased free time, mental distress, and economic difficulties which is supporting the finding of the Italian study. 10 Interestingly, the current results showed an increase in sleeping hours compared to a decrease in sleeping hours in the Italian Study.
In addition, the current study is supporting the Italian findings about the reduction in the smoking habit among the 18-25 age group. 10 In another study in Poland, 40% of smokers declared no change in their smoking level during the lockdown while 45.2% stated an increase in tobacco consumption. 26  T A B L E 4 Relationship between changes in smoking habits since the beginning of pandemic and the other variables (n = 478).
Since the beginning of the pandemic, have you noticed any change related to your smoking habits? Kingdom of 132 smoker participants, those who experienced an increase in their smoking level described smoking as a coping mechanism to deal with psychological stressors such as anxiety, anger, and boredom. 29 In a Greek study, they found a significant difference between increased smoking and age group; all age groups are associated with increased smoking except the young age group (18-29 years), and older age group (60-69 and ≥70 years). 30 These results were different from the findings of the current study in which the highest percentage of smokers who increased their consumption of smoking during the pandemic was among (the 18-35 years) age group.
Another Italian study indicated that there were changes in cigarette smoking habits during the lockdown in 11.8% of the study population (7.7% increased and 4.1% decreased). 31 Alike, the current study showed that 8.6% of the respondents increased their smoking habit and 4.8% decreased.
In a Croatian study, they found an overall increase in smoking consumption during the lockdown, and they also found a significant difference between females and the increase in daily cigarettes number during the lockdown. 32 On the other hand, the current study found no significant difference between gender and changes in smoking habits.
A study from northern Italy of 105 smokers showed that 38% of smoker participants experienced an increase in smoking levels, which was associated with an increase in food consumption (60%). 33 These results are close to our findings where 45.4% of smokers increased their smoking during the lockdown. This increase was associated with increased appetite, weight gain, more night meals, and more sugar and fast-food intake in comparison with those who experienced less smoking during the lockdown.

| CONCLUSION
The results of our study showed that the lockdown had a significant impact on people's lifestyles including smoking habits. Most of our sample's smoker participants experienced a change in their smoking level mostly, an increase. These changes were mostly attributed to the impact of the lockdown on people's life such as increased free time and boredom during the lockdown, financial difficulties, and other various stressors. In general, the study showed that smokers were more likely to adopt an unhealthy lifestyle during the lockdown in comparison with nonsmokers. The results showed that smokers adopted an unhealthy lifestyle represented by daily consumption of sugar and fast food and other unhealthy habits. While those who had a decrease in their smoking level experienced a somehow healthier lifestyle regarding nutrition and other aspects.

| LIMITATIONS
This study tried to provide a general look at changes in people's habits, especially smoking during the worldwide pandemic crisis.
But there were some limitations that we faced through this F I G U R E 2 Reasons for changing in smoking habits during the pandemic among respondents who noticed any change in their smoking habits whether an increase or a decrease in the frequency of smoking (n = 340).
research. One of these limitations is that the study was conducted through an online survey with no possibility to verify data we collected from respondents, but this was the only possible method taking into consideration the extremely strict lockdown the country was put under during that time. In addition, males and less than 18 years old individuals are not fully represented in the current study. writing-original draft; writing-review and editing.